Distraction osteogenesis in Silver Russell syndrome to expand the mandible.

Distraction osteogenesis is a method commonly used to activate bone regeneration in nonunions and osseous defects and for lengthening procedures of tubular bones. This technique involves the sectioning of a bone and the subsequent deliberate, controlled movement of the opposing sectioned edges to lengthen, widen, or reposition a bone, or all three. In this report, a patient with Silver Russell syndrome and severe mandibular hypoplasia was treated by means of distraction osteogenesis of the midsymphysis to widen the mandible in concert with sagittal-ramus osteotomies to lengthen the mandible. This treatment created significantly increased arch length in the mandible, which was necessary to facilitate the patient's orthodontic treatment. We believe this is the first reported case of distraction osteogenesis to widen the mandible with the use of a tooth-borne appliance.

Alveolar bone growth in response to endosteal implants in two patients with ectodermal dysplasia.

The occurrence of alveolar bone growth after placement of endosteal mandibular implants in two edentulous children is reported. The fact that alveolar bone growth occurred in the absence of natural teeth suggests that its growth and preservation is dependent upon biomechanical factors rather than the presence of teeth, as is traditionally thought.

Laser-assisted endoscopic forehead lift.

The periorbital area is one of the most expressive areas of the face, and there are many techniques available that can be used to alter the position of the eyebrows. Traditional surgical browlift techniques use coronal, midforehead, and direct approaches. This article discusses one of the most recent innovations in forehead lifting, the laser-assisted endoscopic forehead lift. A review of the literature describes the numerous available surgical techniques used to change the position of the eyebrow. The surgical technique for the laser-assisted endoscopic forehead lift is then presented in detail and illustrated with the results of two cases.

Objective evaluation of the eyelids and eyebrows after blepharoplasty.

PURPOSE: Surgery of the upper and lower eyelids and eyebrows is primarily designed to enhance the esthetic appearance and provide functional visual field benefits. Paramount to successful surgical results is a carefully executed examination and treatment plan. The preoperative and postoperative evaluation of these individuals has been primarily subjective. This article describes a method for the quantification of periorbital relationships that is of use in the preoperative planning and postoperative evaluation of patients undergoing esthetic surgery of the eyelids and eyebrows. PATIENTS AND METHODS: The photographic records of 15 female patients who had undergone bilateral upper eyelid surgery were examined. None of the patients underwent lower eyelid or eyebrow surgery. Preoperative and postoperative frontal photographs were projected to a standard size, and measurements were made in a standardized fashion. For the comparison of intrapatient and interpatient relationships, objective anthropometric proportions rather than average measurements were used. Therefore, standard periorbital relationships were recorded and expressed as anthropometric ratios. Measurements were recorded for 30 eyes. The preoperative and postoperative relationships were measured and reported as mean values with standard deviation. The relationships studied were: 1) Upper lid height to orbit height, 2) Lower lid height to orbit height, 3) Lid sulcus height to orbit height, 4) Lid sulcus height to upper lid height, 5) Upper iris coverage to iris height, 6) Lower iris coverage to iris height, 7) Orbit height to middle facial height, 8) Medial brow to orbit height, 9) Lateral brow to orbit height, and 10) Eye fissure height to orbit height. Brow heights were measured vertically from a line connecting exocanthion and endocanthion. RESULTS: The postoperative changes in these patients showed the following: Upper lid height, eye fissure height, and brow position were not significantly affected by upper lid blepharoplasty surgery. The sulcus lid height was doubled postoperatively, and upper iris coverage was decreased slightly postoperatively. CONCLUSIONS: The results of the study indicate that the proposed methodology is appropriate for the objective evaluation of periorbital relationships pertinent to esthetic periorbital surgery. Its use is suggested as a diagnostic aid in preoperative planning and postsurgical evaluation.

Cephalometric analysis of profile nasal esthetics. Part III. Postoperative changes after isolated superior repositioning.

In part I of this study, a method for the objective evaluation of profile nasal esthetics was presented and applied to establish normative values for young adult white males and females. Male and female nasal profile esthetics were found to be virtually identical. In part II, the data from the preoperative lateral cephalograms of 13 young adult white female patients with vertical maxillary excess (VME) were compared to the normative data established for females in part I. Results showed a distinct nasal profile in patients with VME. In this part of the study, the postoperative lateral cephalograms of the 13 female patients from part II were analyzed after surgical correction of their vertical maxillary dysplasia to determine if returning the maxilla to a more normal position effected similar changes in nasal profile esthetics. All patients had superior repositioning of the maxilla for which the magnitude of movement was greatest in the superior direction, with the mean movement being 2.3 mm superiorly. The results revealed that surgical correction of VME effected normalization of most of the nasal profile esthetic characteristics.

Cephalometric analysis of profile nasal esthetics. Part II. Patients with vertical maxillary excess.

In part I of this study, a method for the objective evaluation of profile nasal esthetics was detailed, and normative values for males and females were presented. In part II, identical methodology was applied to the preoperative lateral cephalograms of 13 female patients with vertical maxillary excess to determine how the nasal profile esthetics of these patients varies from the norm. This data was compared to the normative data established for females in part I. Results determined that patients with vertical maxillary excess have increased nasal length caused by a more superiorly positioned soft tissue nasion, decreased thickness of soft tissue at rhinion, increased nasal form angle, and increased absolute nasal tip angle related to an increased inclination of the cranial base, increased forward projection of the anterior nasal spine (tip support), and decreased incidence of supratip break. These findings suggest a characteristic appearance similar to the type II nasal characteristic (aquiline form) established in part I.

Cephalometric analysis of profile nasal esthetics. Part I. Method and normative data.

A comprehensive method for the measurement of profile nasal esthetics from standard lateral cephalograms was used for a group of 30 white male and 30 white female patients with skeletal Class I relationships and dental malocclusions only. Linear, horizontal, vertical, and angular hard and soft tissue measurements were made. Results for the two groups were analyzed to determine if there were statistically significant morphologic differences between the sexes. To eliminate differences related to the absolute size differences that characteristically exist between men and women, the results were taken as ratios of a fixed referent (middle third facial height), so that actual intergender differences in shape and form could be determined. The results indicated that male and female noses have essentially identical profile characteristics. The range for both sexes extended from an aquiline nasal type (more classically male) to an upturned type (more classically female). The characteristics of the normative nose for males and females are presented. The proposed methodology provides a standard objective means of evaluating changes in nasal esthetics after maxillary or rhinoplasty surgery.

Anthropometric profile evaluation of the midface in patients with cleft lip and palate.

This study was done to determine those profile anthropometric measurements that are abnormal in the midface profile in patients with cleft lip and palate. The sample population consisted of 30 randomly selected skeletally mature white patients with cleft lip and palate who had been treated by the same team who were accredited by the American Cleft Palate-Craniofacial Association. Twenty patients had unilateral and 10 had bilateral complete clefts. None of these patients had previously undergone orthognathic surgery or definitive rhinoplasty surgery. Fifteen facial anthropometric features were measured on each person's face. The result from this study showed that in patients with cleft lip and palate right versus left side differences did not exist and only four statistically significant differences existed between the unilateral and bilateral cases. However, in all patients, four of these esthetic facial features were consistently and significantly abnormal: obtuse nasofrontal angle: obtuse nasomental angle; a posteriorly positioned infraorbitale relative to globe; and an obtuse general facial angle. Several other features were abnormal in a high percentage of persons in this study. These were lack of supratip break, flat to concave paranasal contour, increased subnasale-alargroove:subnasale-pronasale ratio, decreased nasal protrusion:nasal length ratio, decreased nasolabial angle ratio, decreased maxillary length ratio, increased nasal bridge projection:nasal protrusion ratio, and deficient cheek contour. This data indicates that the major deformity in persons with adult cleft lip and palate exist in the nose and secondarily in other components of the midface.

Cephalometric profile evaluations in patients with cleft lip and palate.

This study was done to determine those abnormal cephalometric features found in adult cleft lip and palate patients. The sample population consisted of 30 randomly selected white patients with cleft lip and palate who were treated by the same team that had been accredited by the American Cleft Palate-Craniofacial Association. Twenty patients had unilateral complete clefts, and 10 had bilateral complete clefts. Thirteen different cephalometric parameters were measured and compared with normal. The results from this study showed that there were few statistically significant differences between the unilateral and bilateral cleft palate patient populations. There were only three measurements that had statistically significant differences between the unilateral cleft patients and the bilateral cleft patients: subnasale-stomion, subnasale-stomion: stomion-soft-tissue menton, and subnasale-lower lip vermillion: lower lip vermillion-soft tissue menton. However, 10 of the 13 measurements had statistically significant variations from normal. These measurements included subnasale=stomion; stomion=soft tissue menton, subnasale=lower lip vermillion; lower lip vermillion=soft tissue menton, interlabial distance, subnasale-perpendicular to upper lip, subnasale-perpendicular to lower lip, subnasale-perpendicular to chin, angle formed between sella turcica=nasion and nasion=A=point, maxillary depth angle, A-point to nasion-pogonion, and angle formed between A=point=nasion and nasion=B=point. The data indicated that a multiplicity of vertical and horizontal abnormalities exist in the person with cleft lip and palate in addition to the well-known transverse deficiencies, and that cephalometric abnormalities are not limited to anteroposterior maxillary deficiency.

Failure of osseointegrated dental implants after diphosphonate therapy for osteoporosis: a case report.

Late loss of initially integrated endosseous implants has generally been attributed to implant overload often the result of inappropriate prosthesis design. Implant placement is rarely contraindicated by preexisting systemic diseases, and no instances of medication-induced implant failure have been reported in the literature. This paper reports a case in which a patient lost five endosseous implants that had successfully osseointegrated and had been restored with a lower hybrid prosthesis approximately 6 months after diphosphonate therapy for osteoporosis was started.

Facial anthropometrics versus cephalometry as predictors for surgical treatment in patients with Class III dentofacial deformities.

The purpose of this study was to determine statistically the relative importance of facial anthropometrics and cephalometry in diagnosing the specific jaw deformity in patients with Class III relationships, ie, the contribution that maxillary deficiency and/or mandibular prognathism made to the Class III deformity. Frontal and right profile photographic views and pretreatment lateral cephalometric radiographs of 20 randomly selected Class III patients were analyzed. Correlation and multiple-regression analyses were utilized to determine the relative importance of clinical diagnosis and cephalometric diagnosis in determining the actual surgery performed. In addition, these analyses determined the relative importance of the various facial anthropometrics and cephalometric parameters critical to making the specific diagnosis of maxillary deficiency and/ or mandibular prognathism. It was concluded that a jaw-specific diagnosis of the Class III population studied was best made with facial anthropometrics rather than cephalometry, and the most important predictive facial features on which to based this diagnosis were paranasal configuration and chin projection. Although the overall cephalometric diagnosis had no statistically significant correlation to the actual surgery preformed, two individual cephalometric parameters, maxillary first molar to pterygoid vertical and mandibular plane angle, were found to statistically correlate to the actual surgery performed. These cephalometric parameters should be scrutinized along with the facial anthropometric data when the jaw-specific surgery is selected.

An alternate elective neck incision.

The classic submandibular incision parallels the inferior border of the mandible and does not follow the resting skin tension lines of the neck. A modified approach is described that initially follows these lines but, as the midbody region is approached, a zigzag incision with legs of 1 to 3 cm and tip angles of approximately 70 to 90 degrees is made. This zigzag skin incision is adjusted for the intended surgery. Subjectively, the results are much more esthetic.

Vascular transformation in cherubism.

Cherubism is a well-known disease entity that was first described by Jones in 1933. A case is presented in which the usual course of the lesion changed dramatically during treatment. The lesion demonstrated unilateral growth with a vascular proliferation after surgical recontouring. Vascular transformation and surgical activation of cherubism, as well as treatment considerations, are discussed.

Orthognathic surgery: the correction of dentofacial deformities.

The field of orthognathic surgery offers ever-improving technology to better rehabilitate patients with dentofacial deformities. Hospital stays have been reduced due to improved surgery and anesthesia. Rigid internal fixation has increased comfort for many patients by eliminating the inconvenience of having the jaws wired together. Most important has been the realization that teamwork between the general dentist and the various specialty disciplines is indispensable for good patient care and the attainment of the very best results.

Maxillofacial esthetics: anthropometrics of the maxillofacial region.

Many artists, orthodontists, and surgeons have proposed guidelines for esthetic facial evaluation, but few have shown a scientific basis for their criteria. Farkas, however, made a substantial contribution to anthropometric facial measurements of adult whites. His raw data were used to develop a comprehensive set of ratios to define the esthetic face. A systematic maxillofacial evaluation derived from Farkas's data is presented, along with a brief description of its clinical application.

The modified superiorly based pharyngeal flap. Part IV. Position of the base of the flap.

The modified superiorly based pharyngeal flap surgical technique developed by Epker et al. was performed on 13 patients with moderate to severe hypernasality. The flap base was attached close to the level of the palatal plane and was found to maintain a consistent longitudinal relationship to the level of the atlas. This technique corrected hypernasality in a range of patients with velopharyngeal incompetence, as predicted.

Correction of the skeletal nasal base in rhinoplasty.

The anatomic abnormalities responsible for the unesthetic nose have been rather extensively described and detailed in clinical studies, applied clinical research (anthropometric) evaluations, and laboratory investigations. These include alterations in the nasal bones, septum, upper lateral cartilage, lower lateral cartilages, skin, nerves, and vessels. However, little attention has been directed to the nasal base, which is frequently deficient and/or asymmetrical in people with nasal deformities. The importance of recognizing this deformity when evaluating patients for rhinoplasty and its subsequent correction as part of the procedure are discussed.

The aged face: the facial manifestations of aging.

Traditionally, cosmetic maxillofacial surgery designed to rejuvenate "the aged face" has been reserved for the elderly. However, any patient with facial manifestations that reflect, but are not limited to, an increased chronologic age is a candidate for esthetic maxillofacial surgery. In this text, the aged face refers to any facial manifestations that are perceived as indices of advanced age beyond an individual's chronologic or desired age. This paper presents a brief outline of the specific facial features that account for the aged face and describes surgical correction.